- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $45.90 / $45.90 / $45.90
| Facility | 26 | $45.90 | $45.90 | $45.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.19 / $82.04 / $113.82
| Professional | | $71.19 | $82.04 | $113.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $32.72 / $36.56 / $52.43
| Professional | 26 | $32.72 | $36.56 | $52.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.28 / $81.50 / $122.19
| Professional | | $69.28 | $81.50 | $122.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $25.29 / $36.13 / $44.23
| Professional | 26 | $25.29 | $36.13 | $44.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.90 / $93.93 / $173.46
| Professional | | $79.90 | $93.93 | $173.46 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $38.36 / $45.16 / $82.09
| Professional | 26 | $38.36 | $45.16 | $82.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.62 / $108.18 / $144.24
| Professional | | $86.62 | $108.18 | $144.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $38.97 / $48.22 / $64.29
| Professional | 26 | $38.97 | $48.22 | $64.29 |